The incidence of lymph node micrometastases in patients pathologically staged N0 in cancer of oral cavity and oropharynx

[Nodal metastasis and value of neck dissection in T1/2 oropharyngeal and hypopharyngeal carcinomas]

BACKGROUND

Due to heterogeneous data, the indication for elective neck dissection (END) in patients with squamous cell carcinoma of the hypopharynx and oropharynx (HPSCC and OPSCC) in stages T1/2N0 is somewhat unclear. Therefore, in this multicenter study, we performed detailed analysis of the metastatic behavior of HPSCC and OPSCC.

MATERIAL AND METHODS

The nodal metastatic patterns of 262 HPSCC and OPSCC patients who had undergone surgery was retrospectively investigated. In addition, recurrence-free and overall survival were recorded. Furthermore, a systematic literature review on the topic was completed.

RESULTS

In patients with HPSCC, a discrepancy between clinical and pathologic N status was recorded in 62.1% of patients vs. 52.4% for p16- OPSCC, and 43.6% for p16+ OPSCC. The occult metastasis rate in cT1/2cN0 primary tumors was 38.9% for HPSCC vs. 17.8% (p16- OPSCC) and 11.1% (p16+ OPSCC). Contralateral metastases occurred in 22.2% of cases for HPSCC at stages cT1/2cN0, compared to only 9.1% for p16- OPSCC, and 0% for p16+ OPSCC patients.Patients with p16+ OPSCC had better recurrence-free and overall survival than p16- OPSCC and HPSCC patients. A direct association between patient survival and the extent of neck surgical therapy could not be demonstrated in our patients.

CONCLUSION

Patients with HPSCC are at risk for bilateral neck metastases from stage cT1/2cN0, justifying bilateral END. Patients with T1/2 OPSCC present with occult metastases ipsilaterally in >20% of cases; however, the risk for contralateral occult metastasis is <10%. Hence, in strictly lateralized cT1/2CN0 tumors, omission of contralateral END may be considered.

Evaluation of micrometastasis and isolated tumor cells in node-negative early-stage oral tongue squamous cell carcinoma: a cross-sectional study in tertiary-level hospitals in eastern India

OBJECTIVE

The present study aimed to investigate the incidence of micrometastasis (MMs) and isolated tumor cells (ITCs) in node-negative early-stage oral tongue squamous cell carcinoma (T1-T2 N0). The secondary objective was to correlate the incidence with the clinicopathologic parameters of age, sex, depth of invasion, pattern of invasion, host lymphocytic response, and size and grade of primary tumor.

STUDY DESIGN

Micrometastasis and ITCs in cervical nodes of 30 patients with early-stage oral tongue squamous cell carcinoma were detected and compared using 3 methods: routine hematoxylin and eosin staining, serial-sectioning at intervals of 150 microns employing hematoxylin and eosin, and serial sectioning pan-cytokeratin immunostaining. Associations with clinicopathological variables were analyzed.

RESULTS

Metastatic tumor cells were detected in the cervical nodes of 2 patients using serial sectioning and immunohistochemistry, resulting in upstaging of 6.6% of all cases. Level I and II lymph nodes were primarily involved.

CONCLUSIONS

Early-stage oral tongue squamous cell carcinoma has a significant potential for MMs that frequently go undetected in routine histopathologic examination. However, laborious and technique-sensitive, serial sectioning in combination with pan-cytokeratin staining (AE1/AE3) may aid in detecting MMs and ITCs in patients with early-stage OTSCC.

Management of clinically node-negative early-stage oral cancer: network meta-analysis of randomized clinical trials

The best treatments for the clinically node-negative (cN0) neck in early-stage oral squamous cell carcinoma (OSCC) patients are a subject of ongoing debate and there is no consensus. A network meta-analysis (NMA) of randomized clinical trials (RCTs) was conducted to determine the most effective treatment and to rank treatments based on their effectiveness. A systematic search was performed in accordance with the PRISMA guidelines to retrieve RCTs that compared therapeutic neck dissection (TND), sentinel lymph node biopsy (SLNB), and elective neck dissection (END). The outcomes analysed were overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and nodal recurrence. Hazard ratios and risk ratios were calculated by direct meta-analysis and NMA. Ten RCTs with a total of 1858 patients were eligible for inclusion. Direct meta-analysis showed END to be superior to TND and comparable to SLNB. The NMA revealed no statistically significant difference between END and SLNB (very low quality evidence) regarding OS, DSS, DFS, and nodal recurrence. However, END was found to significantly improve OS and DFS, and reduce nodal recurrence when compared to TND (moderate quality evidence). END ranked as probably the top treatment option for maximizing OS and DSS, and reducing nodal recurrence in early-stage OSCC, followed by SLNB and TND. There was very low quality evidence supporting SLNB as non-inferior to END for patients with early-stage OSCC. This NMA yielded favourable results for the use of END (with moderate quality evidence) in early-stage OSCC patients, although excellent results have also been obtained with SLNB. However, data in the literature for SLNB are scarce, as this technique has not yet been formalized in many countries. There is a need to further explore SLNB for early-stage OSCC patients, as well as its value in detecting occult lymph node metastases on the contralateral side. More studies comparing morbidity, quality of life, and costs between the different management strategies for the clinically negative neck in early-stage OSCC patients are needed.

Health-related quality of life, functional outcomes, and complications after sentinel lymph node biopsy and elective neck dissection in early oral cancer: A systematic review

BACKGROUND

Elective neck dissection improves survival in early oral cancer. Sentinel lymph node biopsy may also do this with less morbidity. This systematic review compared health-related quality of life, functional outcomes, and complications after sentinel lymph node biopsy and elective neck dissection in early oral cancer.

METHODS

PRISMA guidelines were followed. Thirteen studies met inclusion criteria.

RESULTS

Results favoring sentinel lymph node biopsy were found in complications, scar length and appearance, length of hospital stay, time to drain removal, and objective shoulder measures at timepoints up to 12 months. Where differences in health-related quality of life were found, methodological issues make their clinical significance questionable.

CONCLUSIONS

Sentinel lymph node biopsy was associated with fewer complications and statistically better outcomes in a number of physical measures. There is as yet no strong evidence to suggest it is associated with better health-related quality of life outcomes. While a number of health-related quality of life outcome measures show promise, their interpretation is hampered by methodological concerns. Further rigorous research is required to address this.

Lymph node metastasis in level IIb in oropharyngeal squamous cell carcinoma: a multicentric, longitudinal, retrospective analysis

INTRODUCTION

Nowadays, 70% of patients in Europe and the USA are affected by a p16 + , potentially HPV driven oropharyngeal squamous cell carcinoma. However, despite the improved survival rate in this group, the quality-of-life remains low in cases which neck dissection took place. In this vein, in recent years, some surgeons have considered to avoid dissection of level IIB, proposing a supra-selective non-IIb neck dissection.

MATERIALS AND METHODS

A retrospective, longitudinal, multicentric study was conducted, including patients with pathologically confirmed primary HPV + or HPV - OPSCC who went through surgical treatment for the primary lesion and neck dissection.

RESULTS

141 patients were included. Among them, 99 (70.2%) were male and 42 (29.8%) were female. The mean age was 62 ± 9 years (range 36-81). The most frequent anatomical location was the tonsil in 63 (44.7%) of patients. The most common approach was the classic transoral oropharyngectomy in 51 (36.2%) patients. Immunohistochemistry for p16 was positive in 62 (44%) patients. One-hundred and five (74.5%) patients received a unilateral ND, and a 36 (25.5%) a bilateral ND. Of those, a 12.8% (18/141) of patients were level IIb LN + . According to our results, level IIb ND should be considered in patients underwent therapeutic ND with positive LN metastasis in level IIa (OR = 9.83; 95% CI 3.463-27.917) or III (OR = 6.25; 95% CI 2.158-18.143), advanced (T3/T4) oropharyngeal primary tumors (OR = 3.38; 95% CI 1.366-8.405), and patients with ENE (OR = 6.56; 95% CI 2.182-19.770), regardless of p16 status.

CONCLUSIONS

According to our results, level IIb ND should be considered in patients who underwent therapeutic ND with positive LN metastasis in level IIa or III, advanced oropharyngeal primary tumors, and patients with ENE, independently of p16 status. Prospective data are necessary to definitively ensure the safety of omitting ipsilateral or contralateral level IIb ND in cN - patients with early stage disease.

Critical Review of the Current Evidence on Sentinel Node Biopsy in Oral Cancer

PURPOSE OF REVIEW

With contemporary surgery of the cN0 neck in early oral cancer becoming more selective, sentinel node biopsy (SNB) is gaining popularity as a possible alternate option to elective neck dissection (END). This review attempts to critically appraise the current evidence and highlight pertinent arguments for the use of SNB in early oral cancers.

RECENT FINDINGS

Based on the recent randomized trials, it is imperative to perform an END at the time of primary resection in cN0 oral cancers. The much criticized false negative rate of SNB can be argued to be equal to the regional failure rate after END for pN0 necks, possibly making a case for SNB due to the reduction in number of neck dissections. There still lies ambiguity on the technique, protocols, and benefit of SNB over END. The role of extended histopathological techniques and the implications of micrometastasis and isolated tumor cells for treatment intensification remain questionable. Currently, SNB is an intermediary between routine imaging and END that needs to evolve before it can become a practice changing alternative to END itself. More efforts are needed in standardizing the protocols for SNB.

cN+pN0 disease does not portend a less favorable prognosis compared with cN0pN0 in patients with resected oral cavity squamous cell carcinoma

Background

We compared the clinical outcomes of patients with oral cavity squamous cell carcinoma (OCSCC) with cN+pN0 versus cN0pN0 disease.

Methods

A total of 1309 OCSCC patients with pN0 disease were included. Of them, 1019 and 290 cases had cN0pN0 and cN+pN0 disease, respectively. For comparison purposes, we also examined 799 patients with pN+disease (cN0pN+/cN+pN+, n = 239/560). Subgroup analysis was performed in a propensity score‐matched cohort with cN0pN0 and cN+pN0 disease (n = 284 each).

Results

Compared with cN0pN0, patients with cN+pN0 had a higher prevalence of the following variables: betel chewing, pT3−4, depth ≥10 mm, perineural invasion, and treatment with surgery and adjuvant therapy. The prognosis of patients with cN+pN0 (mean: 52 nodes) and cN0pN0 (mean: 39 nodes) disease was similar both in the original cohort and after propensity score matching. However, the 5‐year outcomes were more favorable for cN+pN0/cN0pN0 compared with cN0pN+/cN+pN+ (local control, 88%/88%/83%/81%; neck control, 94%/93%/82%/76%; distant metastases, 4%/3%/13%/31%; disease‐free survival, 84%/83%/68%/52%; disease‐specific survival, 92%/92%/77%/57%; overall survival, 81%/82%/59%/42%; all p values <0.001; cN+pN0 versus cN0pN0, all p values >0.05). cN+pN0 disease (vs. cN0pN0) was not significantly associated with local control, neck control, distant metastases, and survivals either in univariable or multivariable analyses.

Conclusions

Despite a higher risk factor burden, the prognosis of patients with cN+pN0 disease did not differ from that of cases with cN0pN0. The higher nodal yield and the more frequent use of adjuvant therapy in cN+pN0 disease may explain the lack of significant differences in terms of neck control compared with cN0pN0 disease.

Pretreatment Blood Markers in the Prediction of Occult Neck Metastasis: A 10-Year Retrospective Study

Introduction

The purpose of this study was to clarify the role of inflammatory blood markers in the management of early-stage (T1-T2) oral squamous cell carcinoma (OSCC) of the tongue in patients with a clinically negative neck. 

Materials and methods

We undertook a retrospective chart review of 102 patients with early-stage OSCC of the tongue, subjected to tumor resection and elective neck dissection. Based on postsurgical histopathological examination results, we divided our cohort into pN+ and pN0 groups. Afterwards, we analyzed the role of pretreatment inflammatory blood markers in predicting occult neck metastasis. We also evaluated neutrophil-lymphocyte ratio (NLR) association with the depth of invasion (DOI) of the primary tumor.

Results

We found a significant association of NLR (p=0.001) and monocyte-lymphocyte ratio (p=0.011) with neck status on univariate analysis. Multivariate analysis showed that only NLR (p=0.02) was an independent risk factor for occult metastasis among inflammatory blood markers. Receiver Operating Characteristic curve analysis and Younden’s Index determined the NLR value of 2.96 as the most adequate cut-off value for neck status prediction. NLR values of pretreatment workup also had a significant association with the DOI of the primary tumor (p=0.018).

Conclusion

Our study supports the role of pretreatment NLR in predicting occult neck metastasis in early-stage OSCC of the tongue. It also sheds some light over the potential of NLR as a predictor of the primary tumor’s DOI.

Management of the clinically N0 neck in early-stage oral squamous cell carcinoma (OSCC). An EACMFS position paper

Metastasis of oral squamous cell carcinoma (OSCC) to the cervical lymph nodes has a significant impact on prognosis. Accurate staging of the neck is important in order to deliver appropriate treatment for locoregional control of the disease and for prognosis. The management of the neck in early, low volume disease (clinically T₁/T₂ oral cavity tumours) has long been debated. The risk of occult nodal involvement in cT₁/T₂ OSCC is estimated around 20-30%. We describe the natural evolutionary history of OSCC and its patterns of spread and metastasis to the local lymphatic basins. We discuss most published literature and studies on management of the clinically negative neck (cN₀). Particular focus is given to prospective randomized trials comparing the outcomes of upfront elective neck dissection against the observational stance, and we summarize the results of the sentinel node biopsy studies. The paper discusses the significance of the primary tumour histological characteristics and specifically the tumour's depth of invasion (DOI) and its impact on predicting nodal metastasis. The DOI has been incorporated in the TNM staging highlighting its significance in aiding the treatment decision making and this is reflected in world-wide oncological guidelines. The critical analysis of all available literature amalgamates the existing evidence in early OSCC and provides recommendations in the management of the clinically N₀ neck.

Surgical nodal management in hypopharyngeal and laryngeal cancer

Objective

The aim of this study is to compare pre-therapeutic staging of the loco-regional lymphatic basin and subsequent surgical management in cN0 versus cN+ hypopharyngeal and laryngeal cancer patients.

Methods

We analyzed all hypopharyngeal and laryngeal carcinoma patients treated surgically at a single quaternary medical care and cancer center between 2004 and 2014. We established two groups for patients who underwent neck dissection comparing patients with a low LNR (lymph node ratio) to one with a high LNR. Regarding the cN0 cohort, elective neck dissection was evaluated as a secondary predictor variable. Comorbidities, such as anemia and renal insufficiency, were analyzed as potentially influencing disease-free (DFS) and overall survival (OS).

Results

A total of 310 patients (185 glottic and 125 supraglottic/hypopharyngeal carcinoma) were included. Pre-therapeutic neck MRI-/CT-scan and concomitant neck ultrasound revealed cN+ status in 144 patients resulting in a significant over-staging in 63 patients (44%) who were rated as being pN0 after histological examination. 166 patients were staged cN0 and 21 underwent elective neck dissection (11 local advanced glottic and 10 supraglottic/hypopharyngeal carcinoma). Two cN0 patients showed occult cervical lymph node metastases (10%). Furthermore, we could detect a significant negative impact of the LNR divided by the number of dissected lymph nodes and OS.

Conclusion

The pre-therapeutic clinical evaluation of lymphatic outgrowth is over-staged. OS decreases with increasing LNR divided by the number of dissected lymph nodes. Renal insufficiency and anemia are significant negative factors, decreasing both OS and DFS.

Predictors and Prevalence of Nodal Disease in Salvage Oropharyngectomy

BACKGROUND

Patients with recurrent oropharyngeal cancer often require extensive salvage surgery. For patients with clinically N0 necks, the indication for concurrent neck dissection remains unclear. This study aimed to determine predictors, prevalence, and distribution of nodal disease in patients treated with salvage oropharyngectomy.

METHODS

In a case series with data collection at a single tertiary academic National Cancer Institute (NCI)-designated comprehensive cancer center, this study analyzed patients treated with prior radiation or chemoradiation who had persistent, recurrent, or second primary squamous cell carcinoma of the oropharynx requiring oropharyngeal resection between 1998 and 2017 (n = 95). Clinical and oncologic characteristics and treatment outcomes were collected, and statistical analyses were performed.

RESULTS

The overall rate of nodal positivity was 21% (24/95), and the rate of occult nodal disease was 6% (4/65). Ipsilateral and contralateral level 2 were the most common areas harboring positive nodes. Bivariate analysis showed female sex (p = 0.01), initial overall stage (p = 0.02), and N status (p = 0.03), as well as recurrent overall and T stage (p = 0.05) to be predictors of nodal disease. In the multivariate analysis, recurrent T stage continued to be significantly predictive of pathologic nodal disease. Both computed tomography (CT) and positron emission tomography-CT were moderately accurate in predicting nodal disease in the salvage setting (area under the curve, 0.79 and 0.80, respectively).

CONCLUSION

Occult nodal disease is observed in few patients undergoing salvage oropharyngeal resection. This study identified factors predictive of nodal disease in patients undergoing salvage oropharyngectomy and appropriate diagnostic tests in this setting.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Data Set for the Reporting of Nodal Excisions and Neck Dissection Specimens for Head and Neck Tumors: Explanations and Recommendations of the Guidelines From the International Collaboration on Cancer Reporting

Standardized, synoptic pathologic reporting for tumors greatly improves communication among clinicians, patients, and researchers, supporting prognostication and comparison about patient outcomes across institutions and countries. The International Collaboration on Cancer Reporting is a nonprofit organization whose mission is to develop evidence-based, universally available surgical pathology reporting data sets. Within the head and neck region, lymph node excisions and neck dissections are frequently performed as part of the management of head and neck cancers arising from the mucosal sites (sinonasal tract, nasopharynx, oropharynx, hypopharynx, oral cavity, and larynx) along with bone tumors, skin cancers, melanomas, and other tumor categories. The type of specimen, exact location (lymph node level), laterality, and orientation (by suture or diagram) are essential to accurate classification. There are significant staging differences for each anatomic site within the head and neck when lymph node sampling is considered, most importantly related to human papillomavirus–associated oropharyngeal carcinomas and mucosal melanomas. Number, size, and site of affected lymph nodes, including guidelines on determining the size of tumor deposits and the presence of extranodal extension and soft tissue metastasis, are presented in the context of prognostication. This review elaborates on each of the elements included in the data set for Nodal Excisions and Neck Dissection Specimens for Head & Neck Tumours.

Postoperative radiotherapy is dispensable for OSCC patients with micrometastases in lymph nodes

Lymph node metastasis is a decisive factor for performing postoperative radiotherapy for oral squamous cell carcinoma (OSCC). However, whether OSCC patients with only micrometastasis need postoperative radiotherapy is unclear. In this study, OSCC patients (n = 311) with negative (n = 247), only micrometastasis (n = 44) and macrometastasis (n = 20) were detected and selected by HE staining. Micrometastasis was re-assessed using immunohistochemical staining of cytokeratin (CK) in HE-negative patients to find out the false negative cases. The results indicated that, among the negative lymph node cases (n = 247), the positive rate of CK was 4.94% (n = 12). Besides, the clinical features of the primary tumor in relation to the only micrometastatic status and the value of the postoperative radiotherapy on the only micrometastasis patients were evaluated. Patients with only micrometastasis had higher T stage and inferior worst pattern of invasion (WPOI) than patients without micrometastasis, but they had longer overall survival (OS), metastasis-free survival (MFS), and disease-free survival (DFS) than macrometastasis patients. However, the survival time of only micrometastasis patients with or without postoperative radiotherapy was comparable, even in patients with inferior WPOI. Radiotherapy, however, may only benefit patients with IV/V levels of micrometastasis. These data indicated that postoperative radiotherapy is dispensable for only micrometastasis OSCC patients.

Elucidating the mechanism of miRNA-214 in the regulation of gingival carcinoma

The aim of the present study was to evaluate the expression levels of microRNA (miRNA)-214 in tumor tissue, blood and saliva of patients with gingival carcinoma, and to investigate the mechanisms underlying the infiltration and invasion of gingival carcinoma. Between January 2013 and March 2015, blood and saliva samples, gingival carcinoma tumor specimens and peritumoral tumor tissues were harvested from 56 patients with gingival carcinoma. Blood and saliva samples were also harvested from 33 control patients without gingival carcinoma. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was performed to detect miRNA-214 and protein tyrosine phosphatase gene (PTEN) mRNA levels. Western blotting and ELISA were performed to detect PTEN protein levels. The results of RT-qPCR demonstrated that the expression of PTEN mRNA in tumor tissues, blood and saliva of patients with gingival carcinoma were significantly decreased compared with that of the control group (P<0.05). These findings were consistent were consistent with the results of PTEN protein expression detected via western blotting and ELISA in these samples (P<0.05). Conversely, the expression levels of miRNA-214 in these samples were significantly increased (P<0.05) in patients with gingival carcinoma compared with the control group. The decreased expression of PTEN may be associated with the expression of miRNA-214. miRNA-214 may regulate infiltration and invasion of gingival carcinoma via PTEN. These results suggest that miRNA-214 may be used as a marker of gingival carcinoma.

Indications and extent of elective neck dissection in patients with early stage oral and oropharyngeal carcinoma: nationwide survey in The Netherlands

Background:

Different strategies are available for the management of patients with early (i.e. tumour stage one or two) oral or oropharyngeal carcinoma and a clinically negative neck.

Material and methods:

In 2006, a questionnaire was sent to the eight head and neck cancer centres of the Dutch Head and Neck Oncology Cooperative Group. This questionnaire covered: the factors influencing the decision to perform an elective neck dissection; the neck staging procedure; and the types of neck dissection undertaken.

Results:

All eight questionnaires were returned completed. Respondents indicated that the site (n = 6), size (n = 7) and thickness (n = 6) of the primary tumour were important in decisions regarding elective neck dissection. Ultrasound-guided fine needle aspiration cytology was the most frequently used diagnostic technique (n = 7). Depending on the site and stage of the primary tumour presented, in the different cases 3–7 of the centres would perform an elective neck dissection. Selective neck dissections (i.e. levels I to III/IV) were more frequently performed than modified radical neck dissections.

Conclusion:

There was no uniformity regarding management of the clinically negative neck in patients with early stage oral and oropharyngeal carcinoma, within The Netherlands.

Cervical Metastases Behavior of T1-2 Squamous Cell Carcinoma of the Tongue

INTRODUCTION

The cervical lymph node metastasis (CM) is one of the most important prognostic factors for oral squamous cell carcinoma. Although the frequency and distribution of CM for tongue carcinoma (TC) are well documented in the literature, there is only little data on metastasis patterns depending on the location of the cancer within the tongue.

MATERIALS AND METHODS

In a retrospective study all patients with a T1-T2 TC who were treated between 1997 and 2013 were analysed regarding epidemiological data, risk factors, and tumour parameters such as exact localization, CM.

RESULTS

204 patients (59 ± 15 years; ♀37 %, ♂63 %) were included. At the initial diagnosis 23 % had an advanced tumour stage (III-IV) due to CM. The occurrence of CM was significantly higher for T2, advanced G-status and the localization in the posterior area of the tongue. The presence of CM-but not the recurrence-had a significant influence on the survival rate.

CONCLUSION

The small TC has an aggressive metastatic behaviour depending not only on the classical prognostic factors such as grading and tumour size, but is also strongly influenced by the posterior location within the tongue.

Relevance of level IIb neck dissection in oral squamous cell carcinoma

Background

The purpose of this study was to determine the prevalence of level IIb metastasis in patients with oral squamous cell carcinomas (OSCCs).

Material and Methods

A prospective analysis of 56 patients with OSCC who underwent surgical treatment of the primary lesion with simultaneous neck dissection was performed. During neck dissection, level IIb lymph nodes were separately removed and processed. Neck dissection was bilateral in 26 patients (46%) and unilateral in 30 patients (54%).

Results

The mean number of nodes found in the level IIb specimens was 4.7 (range: 0-8 nodes). The prevalence of metastasis at level IIb was 0% in pN0 necks and 3.4% in pN+ necks, with an overall prevalence of 1.8%. A significant association between metastasis to level IIb and type of neck dissection was observed. There were no isolated metastases to level IIb without the involvement of other nodes in the remaining neck specimen. Four regional recurrences were observed during follow-up.

Conclusions

Based on our findings, we suggest that dissection of the level IIb region in patients with OSCC may be required only in patients with multilevel neck metastasis or if level IIa metastasis is found intraoperatively.

Key words: Oral squamous cell carcinoma, neck dissection, level IIb, metastasis, spinal accessory nerve.

Detection of Cervical Lymph Node Micrometastases in Patients with Squamous Cell Carcinoma of the Oral Cavity, Pharynx and Larynx

Background: The goal of this prospective study was to determine the frequency of micrometastases in patients with squamous cell carcinoma (SCC) of the oral cavity, pharynx and larynx in whom elective neck dissection was indicated (cN0). Patients and Methods: A total of 12 patients (10 males and 2 females) were enrolled in the study. The age ranged 42–73 years (median 62 years). Elective neck dissection was performed in all patients (8 ipsilateral, 4 bilateral) and a total of 256 lymph nodes were removed and sent for microscopic examination. Results: The presence of tumor cells in cervical lymph nodes was found in 5/12 (42%) patients. Micrometastases of SCC were found in two patients and isolated tumor cells (ITC) in two other patients. In the remaining one patient with oropharyngeal SCC, a micrometastasis of papillary thyroid carcinoma (PTC) was detected. Positive lymph nodes were localized in level II in three patients with SCC of larynx, hypopharynx and tongue base, respectively, in level I in one patient with SCC of oral tongue and in level III in one patient with PTC. Conclusion: Our results indicate that SCC of head and neck has a high potential for creating micrometastases which frequency is higher compared to clinically detected macrometastases. Therefore, elective neck dissection or radiotherapy of the neck should be considered in patients with high risk of occult metastases or micrometastases.

Comparative study of sentinel lymph node biopsy in clinically N0 oral tongue squamous cell carcinoma: Long-term oncologic outcomes between validation and application phases

OBJECTIVE

This study tested the long-term outcomes of sentinel lymph node biopsy (SLNB) for oral tongue squamous cell carcinoma (SCC) during the transition from validation to application phase.

MATERIALS AND METHODS

Sensitivity, negative predictive value (NPV), neck control rate, disease-specific survival (DSS), disease-free survival (DFS), and overall survival (OS) were compared in cN0 oral tongue SCC patients from different phases.

RESULTS

A total of 133 SLNs from 61 patients (21 in the validation phase, 40 in the application phase) were harvested. Fourteen SLNs of 12 patients (6 in each phase) were positive for metastasis (occult metastasis rate, 19.6%). Regional recurrences developed from 5 negative SLNs (one in the validation phase, 4 in the application phase), of whom 3 patients were successfully salvaged. Sensitivity and NPV of the validation phase were both 100%, with 60.0% and 88.2% in the application phase. False omission rates were 6.6% (1/15) in the validation group, and 11.7% (4/34) in the application group, respectively. The neck control rate was 95.2% in the validation phase and 97.5% in the application phase (p=0.52). No differences were evident in DSS, DFS, and OS between the two phases (DSS: 92.5% vs 95.2%, p=0.69; DFS: 85.0% vs 90.4%, p=0.40; OS: 90% vs 85.5%, p=0.62). Subgroup analyses between negative- and positive-SLNs within each phase revealed no significant differences in all endpoints.

CONCLUSION

Given higher false negative cases in the application phase, stringent strategy of follow-up and salvage treatment is mandatory to maintain acceptable outcomes.

Sentinel lymph node biopsy in clinically N0 T1-T2 staged oral cancer: the Dutch multicenter trial

OBJECTIVES

Results of the Dutch multi-institutional trial on sentinel lymph node (SLN) biopsy in oral cancer.

PATIENTS AND METHODS

Patients were consecutively enrolled from 4 institutions, with T1/T2 oral cancer and cN0 neck based on palpation and ultrasound guided fine needle aspiration cytology. Lymphatic mapping consisted of preoperative lymphoscintigraphy. For intraoperative SLN detection a gamma-probe was used and in some patients additional blue dye. SLN negative patients were carefully observed, SLN positive patients were treated by neck dissection, radiotherapy or a combination of both. Endpoints of the study were risk of occult lymp node metastases, neck control, accuracy, 5-year disease-free survival (DFS), overall survival (OS) and disease-specific survival (DSS).

RESULTS

Twenty of 62 patients (32%) had positive SLNs. Macrometastases were found in 9 patients, micrometastases in 8, and isolated tumour cells in 3 patients. Median follow-up was 52.5 months. Of the 42 SLN negative patients, 5 developed a regional recurrence of whom 4 patients could be successfully salvaged. DFS, OS and DSS of SLN negative patients were 72.0%, 92.7% and 97.4%, and for SLN positive patients these numbers were 73.7%, 79.7%, 85.0%, respectively (DFS: p=0.916, OS: p=0.134, DSS: p=0.059, respectively). Neck control rate was 97% in SLN negative and 95% in SLN positive patients. Sensitivity was 80% and negative predictive value 88%.

CONCLUSION

SLN biopsy is able to reduce the risk of occult lymph node metastases in T1/T2 oral cancer patients from 40% to 8%, and enables excellent control of the neck.

Can contrast-enhanced ultrasound distinguish malignant from reactive lymph nodes in patients with head and neck cancers?

The purpose of this study was to investigate the utility of contrast-enhanced ultrasound in differentiating benign from malignant cervical lymph nodes in patients with squamous cell carcinoma of the head and neck. A consecutive series of 17 patients with known head and neck malignancy scheduled for neck surgery and lymph node clearance were recruited for contrast-enhanced ultrasound evaluation. Sonographic signal intensity as a function of time, comparing features of time to peak, time to arrival and time to wash-out, was quantified. The selected node was removed surgically and submitted for histology. Contrast-enhanced ultrasound examination had 100% sensitivity and 85.7% specificity for lymph node involvement. Functional analysis revealed contrast peaks significantly earlier in the malignant nodes (mean ± standard deviation) of 24.14 ± 2.7 s compared with 29.33 ± 3.4 s (p = 0.0128). Contrast-enhanced ultrasound holds promise in the detection and characterization of metastatic nodes that would not be diagnosed as abnormal on the basis of conventional ultrasound criteria.

Matrix metalloproteinase-7 and matrix metalloproteinase-25 in oral tongue squamous cell carcinoma

BACKGROUND

Predicting the clinical course of early-stage oral tongue squamous cell carcinoma (SCC) is challenging. As matrix metalloproteinases (MMPs) are enzymes associated with invasion, metastasis, and poor survival in many cancers, we examined MMP-7 and MMP-25 in oral tongue SCC.

METHODS

We used tissue microarray (TMA) technique and immunohistochemistry to study the expression of MMP-7 and MMP-25 in 73 patients with stage I to II oral tongue SCC and compared their immunoexpressions with clinical data.

RESULTS

Immunohistochemistry revealed MMP-7 and MMP-25 expression in 90% (n = 63 of 70) and 90% (n = 64 of 71) of the tumors, respectively. MMP-7 protein expression was associated with presence of occult cervical metastases (odds ratio [OR], 3.67; p = .013), increased invasion depth (OR, 4.60; p = .005), and higher tumor grade (OR, 3.30; p = .007). MMP-7 expression was predictive for poor outcome (p = .021). Immunostaining of MMP-25 did not correlate with any clinical parameters.

CONCLUSION

We conclude that MMP-7, but not MMP-25, expression may have prognostic significance in early-stage oral tongue SCC.

Multi-institutional investigation of the prognostic value of lymph nodel yield in advanced-stage oral cavity squamous cell carcinoma

BACKGROUND

Although existing literature provides surgical recommendations for treating occult disease (cN0) in early-stage oral cavity squamous cell carcinoma (SCC), a focus on late-stage oral cavity SCC is less pervasive.

METHODS

The medical records of 162 patients with late-stage oral cavity SCC pN0 who underwent primary neck dissections were reviewed. Lymph node yield as a prognosticator was examined.

RESULTS

Despite being staged pN0, patients that had a higher lymph node yield had an improved regional/distant control rates, disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). Lymph node yield consistently outperformed all other standard variables as being the single best prognostic factor with a tight risk ratio range (RR = 0.95-0.98) even when correcting for the number of lymph nodes examined.

CONCLUSION

The results of this study showed that lower regional recurrence rates and improved survival outcomes were seen as lymph node yield increased for advanced T classification oral cavity SCC pN0. This suggests that increasing lymph node yield with an extended cervical lymphadenectomy may result in lower recurrence rates and improved survival outcomes for this advanced stage group.

Expression characteristics of astrocyte elevated gene-1 (AEG-1) in tongue carcinoma and its correlation with poor prognosis

Astrocyte elevated gene-1 (AEG-1) expression is increased in diverse human cancers and plays a vital role in tumorigenesis and progression. The aim of this study was to investigate the clinicopathologic features and prognostic significance of AEG-1 in squamous cell carcinoma of the tongue (TSCC). Immunohistochemistry (IHC) was performed to examine AEG-1 protein expression in paraffin-embedded tissues from 93 patients with TSCC. Real-time PCR and western blot analyses were employed to examine AEG-1 expression in 4 pairs of primary TSCC and adjacent non-cancerous tissues from the same patient. Immunohistochemical results revealed that the positive rate for AEG-1 in TSCC tissues (48.39%, 45/93) was higher than that in the normal tongue tissues (10.00%, 3/30) (P < 0.001). These results were further confirmed between TSCC tissues and matched adjacent non-cancerous tissues by Western blot and RT-PCR. Simultaneously, AEG-1 protein level was positively correlated with differentiation degree (P < 0.001), clinical stage (P < 0.001), T classification (P = 0.007) and N classification (P = 0.012). Furthermore, patients with higher AEG-1 expression had shorter overall survival time. Multivariate analysis (Cox regression) also suggested that AEG-1 expression was an independent prognostic indicator for TSCC (P = 0.043). Our results indicate that AEG-1 expression is closely associated with carcinogenesis and progression of TSCC, and may represent a novel and valuable predictor for prognostic evaluation of TSCC patients.

Focal adhesion kinase overexpression: correlation with lymph node metastasis and shorter survival in oral squamous cell carcinoma

BACKGROUND

Focal adhesion kinase (FAK) has been identified as a key mediator in tumor progression. The objective of this study was to determine the role of FAK as a predictor of neck node metastasis and poor prognosis in oral squamous cell carcinomas (OSCCs).

METHODS

FAK expression in normal oral mucosa and in 69 OSCCs was examined by immunohistochemistry, and the percentage of stained cells was recorded. The correlation of these findings with clinicopathologic variables and survival was studied.

RESULTS

FAK expression in OSCCs was heterogeneous: 33.3% of cases showed weak expression; 23.2%, moderate expression, and 33.3% cases showed high expression. FAK expression significantly correlated with tumor size (p = .010), neck node metastasis (p = .01), and local tumor recurrence (p = .01). FAK expression was an independent prognostic factor in the survival analysis (p = .017).

CONCLUSIONS

Increased expression of FAK may play a role in invasiveness and metastasis of OSCCs, which contribute to poor prognosis and low survival.

Immunohistochemistry, a valuable tool in detection of cervical lymph node micrometastases in head and neck squamous cell carcinoma: a prospective study

The regional failure after comprehensive clearance of neck metastasis and consequent pathological report of N0 disease has been reported fairly frequently. The role of recurrence of disease in the neck in the cases has been variously reported by different authors. The light microscopy does not detect the micrometastasis and the specimen is reported negative for metastasis. The presence of micrometastasis (the reason for neck failure) has been reported by many studies as 5-58 % (mean 19.6 %). These figures are significantly high. The present study was done to ascertain the micrometastasis after comprehensive neck clearance (pN0 report). Two groups of patients were included in this study. (1) Group I included patients with N0 necks (80 patients). (2) Group II included Patients with N+ necks (107 patients). We found that 20 % case were reported N0 (Group I) in light microscopy but on immunohistochemistry these were positive for disease. 15 % upstaging was reported in N+ cases (Group 2). Immunohistochemistry has been more sensitive for cancer detection and has significantly changed the tumor staging and its consequent management.

Prognostic significance of matrix metalloproteinase-2, -8, -9, and -13 in oral tongue cancer

BACKGROUND

Oral tongue squamous cell carcinoma (OTSCC) often metastasizes to cervical lymph nodes. Mechanisms of this disease progression are not fully known. We aimed at finding new predictive markers for diagnosis and disease monitoring.

METHODS

Seventy-three consecutive T1N0M0 and T2N0M0 OTSCC patients treated at Helsinki University Central Hospital, Helsinki, Finland, in 1992-2002 were included. Tissue array blocks were prepared from primary tumors and immunostained. Immunoexpression of matrix metalloproteinase (MMP)-2, -8, -9, and -13 was compared with patient characteristics and outcome.

RESULTS

Nuclear expression of MMP-13, but not cytoplasmic expression of MMP-2, -8, and -9, was associated with invasion depth (P = 0.017) and tumor size (P = 0.008). Furthermore, high nuclear MMP-13 expression was predictive of poor outcome (P = 0.042).

CONCLUSION

Our results suggest that especially MMP-13 may be regarded as a prognostic biomarker in OTSCC.

The role of salivary cytokine biomarkers in tongue cancer invasion and mortality

Squamous cell carcinoma of the tongue (TSCC) has one of the poorest prognoses of head and neck cancers. This study aims to improve early detection of the disease by identifying salivary biomarkers that can identify a spectrum of patients progressing from high-risk to TSCC. We also examine the mortality of exophytic and endophytic TSCC, expecting the elevated cytokine levels in endophytic patients to be associated with a shorter survival. Saliva was collected from patients with TSCC and controls and cytokine protein levels were measured. Specimens were collected from the Los Angeles County (LAC) + University of Southern California (USC) and USC University Hospital clinics. A convenience sample of patients with TSCC was divided into endophytic (n=10) and exophytic (n=8) cancer by physician diagnosis. Controls were divided into 4 groups of 14 based on their high-risk smoking and drinking behaviors.

MAIN OUTCOME MEASURES

The levels of IL-1α, IL-6, IL-8, VEGF-a and TNF-α in saliva were measured using quantitative ELISA and compared using two-way ANOVA. All five cytokines were elevated in the endophytic TSCC group compared to other groups, which correlated with the decreased survival rate (10.4 months) in this group compared to exophytic TSCC (24 months). IL-1α, IL-6, TNF-α and VEGF were also elevated in the exophytic TSCC group compared to smoking-drinking controls. Salivary levels of IL-1α, IL-6, IL-8, VEGF-a and TNF-α can identify the progression of TSCC from high-risk to neoplasm, serving as potential biomarkers for cancer screening and early detection. The correlation with survival implies a prognostic benefit and could serve as a tool for management decisions and future treatment targets.

Long-term surgical complications in the oral cancer patient: a comprehensive review. Part I

OBJECTIVES

Oral and oropharyngeal cancer remains among the top ten most common malignancies in the United States and worldwide. Over the last several decades the approach to treatment of oral cancer has changed very little with regards to primary tumour extirpation while the approach to the "at risk" lymph nodes has evolved significantly. Perhaps the most significant change in the surgical treatment of cancer is the introduction of free flap for reconstruction post resection. Despite these surgical advances, oral cancer ablation, still results in the sacrifice of several functional and aesthetic organs. The aim of this article was to provide a comprehensive review of the potential long-term complications associated with surgical treatment of oral cancer and their management.

MATERIAL AND METHODS

The available English language literature relevant to long-term surgical complications associated with surgical treatment of oral cancer was reviewed. The potential common as well as rarer complications that may be encountered and their treatment are summarized.

RESULTS

In total 50 literature sources were obtained and reviewed. The topics covered in the first part of this review series include ablative surgery complications, issues with speech, swallowing and chewing and neurologic dysfunction.

CONCLUSIONS

The early complications associated with oncologic surgery for oral cancer are similar to other surgical procedures. The potential long-term complications however are quite challenging for the oncologic team and the patient who survives oral cancer, primarily due to the highly specialized regional tissues involved in the surgical field.

Evidence for the changes of antitumor immune response during lymph node metastasis in head and neck squamous cell carcinoma

OBJECTIVE

This study aimed to elucidate the differences in antitumor immune responses between primary tumors and metastatic regional lymph nodes in head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

The clonality of tumor-infiltrating lymphocytes in tissue specimens from 17 HNSCC patients was examined regarding their T-cell receptor (TCR) repertoires and their complementary determining region 3 (CDR3) size spectratyping. Cytokine expression profiles and T-cell phenotypes also were measured by using real-time quantitative polymerase chain reaction.

RESULTS

The host immune responses to HNSCC cells, reflected by the TCR repertoire, differed between primary tumors and metastatic lymph nodes. CD8+-T cells and T helper type 1 (TH1)/T cytotoxic 1 (TC1) cell cytokine production in metastatic and nonmetastatic lymph nodes were similar.

CONCLUSIONS

The antitumor immune response to HNSCC cells changes during lymph node metastasis, and HNSCC cells can escape the cytotoxic immune responses mediated by CD8+-T cells and TH1/TC1 cells. These results suggest that lymph node metastasis might be associated with changes in the nature of the primary tumor antigens.

Contemporary management of cancer of the oral cavity

Oral cancer represents a common entity comprising a third of all head and neck malignant tumors. The options for curative treatment of oral cavity cancer have not changed significantly in the last three decades; however, the work up, the approach to surveillance, and the options for reconstruction have evolved significantly. Because of the profound functional and cosmetic importance of the oral cavity, management of oral cavity cancers requires a thorough understanding of disease progression, approaches to management and options for reconstruction. The purpose of this review is to discuss the most current management options for oral cavity cancers.

Bmi-1 expression predicts prognosis in squamous cell carcinoma of the tongue

BACKGROUND

The prognosis of squamous cell carcinoma of the oral tongue is poor and it would be beneficial to find prognostic markers to better adjust treatment. Bmi-1 controls cell cycle and self-renewal of tissue stem cells, transcription factor c-myc affects cell proliferation and apoptosis, and Snail regulates epithelial-mesenchymal transition. The expression of these markers has been connected to prognosis in many cancer types.

METHODS

Bmi-1, c-myc, and Snail expressions were studied in our material consisting of 73 primarily T1N0M0 oral tongue carcinoma patients. We compared the immunoexpressions of Bmi-1, c-myc, and Snail with clinical parameters including the degree of histological differentiation, tumour size, TNM classification, depth of invasion, and resection margins. In addition, survival analyses were performed, comparing disease-free survival time with the registered protein expression of the markers mentioned above.

RESULTS

A significant correlation between Bmi-1 protein expression and recurrence (log-rank test, P=0.005) was detected. Snail and c-myc expression did not correlate with prognosis. Snail expression correlated with histopathological grade (Fisher's exact test, P=0.007) and with the invasion depth of tumours (chi(2)-test, P=0.037).

CONCLUSION

Negative Bmi-1 immunoexpression might serve as a marker of poor prognosis in oral tongue carcinoma patients.

Laser-capture microdissection and protein extraction for protein fingerprint of OSCC and OLK

To find new biomarkers and establish histopathology protein fingerprint models for early detection of oral squamous cell carcinoma (OSCC), laser capture microdissection (LCM) technology was utilized in 21 OSCC tissues and 7 oral leukoplaque (OLK) tissues as well as their adjacent normal tissues. Each sample was then detected by SELDI-TOF-MS technology and CM10 protein chip as well as bioinformatics tools. Three proteomic biomarker patterns were identified. Pattern 1 distinguishes patients with OLK from healthy individuals. Pattern 2 distinguishes patients with OSCC from healthy individuals. Pattern 3 distinguishes patients with OSCC from patients with OLK. The analysis yielded both a specificity and a sensitivity of 90.48% for pattern 1, a specificity of 100.00% and a sensitivity of 85.71% for pattern 2, and a specificity of 100.00% and a sensitivity of 85.71% for pattern 3. Proteome mass/charge 3714, 3515, and 4944 built the distinguished protein peaks between the OSCC tumor and adjacent normal tissues. The accuracy of the blind prediction was 90.48% (38/42). M/Z 15122 and 7569 built the distinguished protein peaks between the OLK and adjacent normal tissues. M/Z 3738 and 11366 built the distinguished protein peaks between the OSCC and the OLK. By employing LCM technology combined with SELDI-TOF-MS technology and bioinformatics approaches, histopathology would not only facilitate the discovery of better biomarkers for OSCC and OLK, but also provide a useful tool for molecular diagnosis by potential biomarker.

Proteomic diagnosis models from serum for early detection of oral squamous cell carcinoma

The early diagnosis of oral squamous cell carcinoma (OSCC) is crucial to prevent deformity and malfunction post-surgery, as well as to allow clinicians to make a rapid decision about treatment. The aim of this study was to search a serum diagnostic model at a molecular level for OSCC. After collection and processing of serum from 28 OSCC patients and 32 healthy volunteers in the Department of Stomatology at the university hospital, samples were detected using Surface Enhanced Laser Desorption Ionization Time of Flight Mass Spectrometry (SELDI-TOF-MS) technology with CM10 protein chip and bioinformatics. Seven protein mass peaks were screened out to build a serum diagnosis model with a significant P value, respectively, and the sensitivity, specificity, and total accuracy were 93.75%, 92.86%, and 93.33%. The use of serum protein fingerprint provides a promising approach for early diagnostics, which could benefit determining preventative and therapeutic stages of patients with OSCC.

Micrometastases and isolated tumour cells in sentinel lymph nodes in oral and oropharyngeal squamous cell carcinoma

BACKGROUND

The occurrence of micrometastases (MMs) and isolated tumour cells (ITCs) in oral sentinel lymph node (SLN) biopsy is poorly known, and the definitions and clinical significance of MMs and ITCs in SLN biopsy are controversial. We compared the UICC/TNM definitions of MMs and ITCs with our previously published sentinel node protocol to assess how the adoption of the UICC/TNM criteria would affect the staging of nodal micrometastatic disease.

METHODS

Of 107 patients who had a SLN biopsy and pathology at 150 microm intervals, 35 with metastatic tumour were included. Eighty-six SLNs were reassessed using the UICC/TNM definitions for MMs and ITCs. Findings were linked to the final pathology in the subsequent neck dissection.

RESULTS

Initial H&E sections showed metastases in 24 patients (in 34 out of 61 SLN), 8 of whom (9 SLNs) had MMs. Additional step serial sections revealed metastatic deposits in a further 11 patients (15 out of 25 SLNs were positive) which were reassessed as MMs (6 patients) or ITCs (5 patients). Subsequent neck dissection revealed additional metastases in 46% of patients with MM, whilst one of the ITC patients had subsequent neck metastases (20%).

CONCLUSION

Despite some limitations, the UICC/TNM classification provides an objective, uniform method of detecting MMs and ITC's. Unlike in cases with ITC, metastases in other non-SLNs were common when a micrometastasis was detected in a SLN, indicating need for further treatment of the neck.

Elective management of the neck in oral cavity squamous carcinoma: current concepts supported by prospective studies

The incidence of occult cervical metastasis in oral cavity cancer, even in early stages, is significant, necessitating elective treatment of the neck in a majority of cases. There is no method of imaging or other examination that will detect microscopic foci of metastatic disease in cervical lymph nodes. Immunohistochemical and molecular analysis of neck specimens reveals the incidence of occult metastases to be higher than revealed by light microscopy with ordinary hematoxylin and eosin staining. The neck may be treated electively by surgery or irradiation. Surgery has the advantage of permitting pathological staging of the neck, avoiding unnecessary radiation treatment and indicating cases where adjuvant therapy should be employed. As oral cavity cancer rarely metastasizes to level V, a radical or modified radical neck dissection of all five node levels is not necessary. Selective dissection of levels I-III ("supraomohyoid neck dissection") is the usual procedure of choice for elective dissection of the neck. Most of the relatively small number of isolated metastasis to level IV are from primary tumours of the tongue, which are known to produce "skip" metastases. Thus an "extended supraomohyoid neck dissection" of levels I-IV is recommended by some authors for elective treatment of the neck in tongue cancer. A number of recent prospective multi-institutional studies have demonstrated that sublevel IIB is rarely involved with isolated metastasis from oral cavity primary tumours, except from some tongue cancers. Thus it is justifiable to omit dissection of sublevel IIB in elective treatment of most cases of oral cavity cancer. Bilateral neck dissection should be performed in elective treatment of tumours involving midline structures, and in patients with ipsilateral neck metastasis.

Detection of lymph node micrometastases in patients with squamous carcinoma of the head and neck

While the significance of large cervical node metastases in patients with head and neck squamous carcinomas is well established, the import of a finding of regional nodal micrometastases (where a micrometastasis is defined as a metastatic deposit greater than 0.2 mm and not greater than 2.0 mm in greatest dimension) or isolated tumor cells in those patients is less clearly understood. Some earlier investigators have suggested that finding micrometastases does not have an impact on prognosis; some later investigators, however, have taken issue with this position, arguing that finding either micrometastases or isolated tumor cells might portend a poorer prognosis for head and neck cancer patients. At this juncture, it is difficult to advance a single recommendation for handling a finding of micrometastases or isolated tumor cells. It would be helpful if two courses of action were followed: first, while the detection of micrometastases and isolated tumor cells remains an investigatory practice, data should be collected and analyzed with an eye to discerning whether such findings are indeed of significance to the individual head and neck cancer patient. Second, rigorous definitions of micrometastases and isolated tumor cells (such as the definitions suggested here) should be developed and widely employed so as to permit ready comparison between the results as they are reported by different investigators.

Elective supraomohyoid neck dissection for oral cavity squamous cell carcinoma: Is dissection of sublevel IIB necessary?

Spinal accessory nerve (SAN) dysfunction and related shoulder disability are common consequences of supraomohyoid neck dissection (SOHND). Nerve dysfunction is usually attributed to excessive nerve traction or devascularization during clearance of the lymph nodes posterior and superior to the SAN (sublevel IIB). The need for routine dissection of this sublevel with elective neck dissection has recently been questioned. This review article discusses whether preserving sublevel IIB lymph nodes is justified in elective SOHND for patients with squamous cell carcinoma (SCC) of the oral cavity. A review of the literature was conducted on studies of sublevel IIB dissection in elective SOHND for SCC of the oral cavity. Only two studies have prospectively investigated the incidence of lymph node metastasis in patients with clinically N0 SCC of the oral cavity. Data from these two prospective pathologic and molecular analyses of neck dissection specimens, including 122 patients with N0 oral cancer, revealed 7.3% with positive neck nodes at sublevel IIB for oral cancer in general, and 12% for tongue cancer in particular. When considering the merits of preservation of sublevel IIB, the benefit of preservation of SAN function has to be weighed against potentially reduced oncologic control.